Basic Information
Provider Information | |||||||||
NPI: | 1932154713 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JACKSON SURGICAL ASSOCIATES. PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 395 HOSPITAL BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383052080 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316647395 | ||||||||
FaxNumber: | 7316640057 | ||||||||
Practice Location | |||||||||
Address1: | 395 HOSPITAL BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383052080 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316647395 | ||||||||
FaxNumber: | 7316640057 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 10/22/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEBSTER | ||||||||
AuthorizedOfficialFirstName: | SALLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7316647395 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 9997 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 107276 | 01 | TN | BLUE CROSS | OTHER | 3053968 | 05 | TN |   | MEDICAID | 4005486 | 01 | TN | BLUE CROSS | OTHER | 1609871821 | 01 | TN | NPI | OTHER | 1356346142 | 01 | TN | NPI | OTHER | 3060477 | 01 | TN | BLUE CROSS | OTHER | 1376548503 | 01 | TN | NPI | OTHER | 3089277 | 05 | TN |   | MEDICAID | 3862742 | 05 | TN |   | MEDICAID |